This policy version was replaced November 28, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).
Vitamin or mineral deficits can occur in patients whose food intake has been restricted or when absorption of essential nutrients is impaired. In most cases, imbalances can be corrected through consuming a balanced diet along with oral supplementation of vitamins and/or minerals that are lacking. Infusion or injection of vitamins and/or minerals may be done when urgent supplementation is needed to treat or prevent a medical condition or when oral supplementation is contraindicated. In contrast to total parenteral nutrition, which contains vitamins, minerals, proteins, sugars, and fats, infusion or injection of vitamins and/or minerals is not a complete form of nutrition
Note: For iron infusion, see policy II-243, Intravenous Iron Replacement Therapy.
I. Infusion or injection of vitamins and/or minerals may be considered MEDICALLY NECESSARY AND APPROPRIATE when BOTH of the following criteria are met:
II. Infusion or injection of vitamins and/or minerals is considered EXPERIMENTAL/INVESTIGATIVE for all other indications not addressed by the criteria above, including but not limited to the following:
No additional statements.
Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.
Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.